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ACNM Policy Update 9/27/14

Federal Issues

1.  ACNM Survey Looks at Marketplace Coverage for Midwifery Services

2.  ACNM Resource Helps Identify which State is the Best Place to be a Midwife

3.  National Governors Association Recommends Easing Restrictions on PAs

4.  Be Sure to Share this Update with CNMs Who are not yet ACNM members


State Issues

1.  Proposed Collaborative Requirement Rules in Louisiana

2.  Change in Payments for Early Elective Delivery in Montana



Federal Issues

1.  ACNM Survey Looks at Marketplace Coverage for Midwifery Services

On September 18, ACNM released the results of a survey of health insurers that offer coverage through the Health Insurance Marketplaces, asking them about the inclusion of midwives in plan provider networks as well as coverage for midwifery services.  The survey found the following:

• Twenty percent of plans do not contract with CNMs to include them in their provider networks, even though CNMs are licensed to practice in all 50 states and the District of Columbia.

• Seventeen percent of plans do not cover primary care services offered by CNMs, even though ACNM standards defining the scope of practice for these providers, often incorporated by reference by state law, include primary care services.

• Fourteen percent of plans indicated they impose restrictions on CNM practice that conflict with their scope of practice under state laws and regulations.

• Twenty-four percent of plans will not cover CNM professional services provided in a birth center and 56% will not reimburse CNMs for home birth services.

• Fifty percent of plans do not pay CNMs the same amount paid to a physician when they perform and bill for the same service.  

• Ten percent of plans that contract with CNMs do not list them in their provider directories, making them invisible to potential and current enrollees. Forty percent of plans listing CNMs in their provider directories list them under the obstetrician-gynecologist category, which may make it difficult for women searching for “midwives” to find them.

• Forty-seven percent of plans do not contract with birth centers to cover facility costs associated with births in that setting, despite studies showing very good outcomes and low costs associated with these facilities.

• Among those contracting with birth centers, 18% do not make a payment to the birth center for their services that is distinct from the payment made to the professionals working therein.

• Eight percent of plans contracting with birth centers indicated they did not list them in their provider directory.

The survey included questions about CMs, but because of a very small sample size these results were generally not included in the report.  The survey also asked about inclusion of CPMs when the plan was located in a state where CPMs are authorized to practice. 

ACNM has issued an invitation to HHS to discuss the survey results and their implications for the Department's efforts to ensure network adequacy and the absence of discrimination among providers on the part of health plans.  We will report on the outcome of those discussions after they occur.  

2.  ACNM Resource Helps Identify which State is the Best Place to be a Midwife

So, where's the best place in the country to practice as a midwife?  A slide deck recently developed by ACNM can help you answer that question for yourself.  It provides data on where CNMs/CMs are located and how their numbers compare to state populations, data on births attended by CNMs/CMs (and CPMs) in each state, a set of slides on the impact of Medicaid as your most important payer, and a quick look at variations in the cesarean rate.  Finally, there is some state by state salary information.

To help midwives who are newer in their careers, it also includes a very brief overview of the Medicare physician fee schedule and some pointers on obtaining an NPI and a Medicare number.

While the slide deck doesn't actually seek to answer the question of which state is best, you can draw your own conclusions.  I personally believe that the folks choosing to practice in Arkansas and Louisiana are heros and that midwives in Florida might be tempted to trade in the sunscreen for a snow shovel and move to Alaska.

One option that the slide deck does not cover is that of the uniformed services.  If you join the military, they can help pay for your education and you get to choose which state to get licensed in, so can select the most advantageous one.  Full practice authority is the norm in military treatment facilities, so you don't have to worry about supervision or a legalistic collaborative agreement, and hospital privileges are assured.  Perhaps best of all, a physician who is a captain has to salute a CNM who is a major.

3.  National Governors Association Recommends Easing Restrictions on PAs

The National Governors Association (NGA) has released a report on physician assistants (PAs) that has significant implications for efforts by the PAs and other APRN groups to improve the regulatory environment under which they work in the states.

The NGA concluded that state laws and regulations may not be broad enough to encompass the professional competencies of PAs.  In addition, state statutes and regulations impose widely diverse restrictions on physicians’ ability to delegate authority to PAs, which, in some instances, are overly strict. The report goes on to say that Governors seeking to take full advantage of the PA workforce in their states may review the laws and regulations affecting the profession and consider actions to increase the future supply of PAs.

The report on PAs builds on a previous publication the NGA issued regarding NPs which concluded that states should give consideration to reducing regulatory barriers to NP practice and ensuring that they are appropriately reimbursed.

While these reports do not mention CNMs, the fact that the NGA has taken such a strong stand on NP and PA practice is encouraging.  Many of the points made by the NGA about NPs and PAs could also be made with regard to CNMs.

4.  Be Sure to Share this Update with CNMs Who are not yet ACNM members

Many CNMs are not members of ACNM and we want them to know what the association is doing to support midwifery.  Please forward this note on to any you know who are not yet ACNM members.  When they join, these updates, as well as all of the other benefits of membership will come to them automatically. 

State Issues

1.  Proposed Collaborative Requirement Rules in Louisiana

The Louisiana affiliate and the national office have submitted comments to the Board of Medical Examiners in opposition to proposed rules governing the collaborative relationship between APRNs and physicians. If adopted, the rules, among other things, would require APRNs to have a secondary (back-up) collaborating physician and implement new “quality assurance” standards, including mandatory monthly chart reviews. A public hearing is scheduled for late September; ACNM will update members on the status of the rules as new information becomes available.

2.  Change in Payments for Early Elective Delivery in Montana

On September 18, the Montana Department of Public Health and Human Services adopted new rules that will decrease Medicaid payments to physicians and advanced practice nurses for early elective deliveries (EED) by disallowing the application of the maternity policy adjustor effective October 1. EED is defined in the new rules as “either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation.” The Department specifically cites to evidence that implementation of a policy to decrease the rate of reimbursement decreases the number of EEDs and improves neonatal outcome as their rationale for the new rule.

 Should you have questions about these issues, please contact Jesse Bushman, ACNM’s Director of Advocacy and Government Affairs at [email protected] or 240-485-1843. 

Not an ACNM member?  You can access all of the member benefits, including receipt of every ACNM Policy Update, by joining today.  

Want to take action or get involved?  Contact ACNM's Government Affairs Committee.

Don't have the time or energy to get involved, but still want to contribute?  Support the Midwives-PAC.



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American College of Nurse-Midwives.
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